Description

The Prior Authorization and Patient Liaison for Retina is responsible for managing all prior authorizations and copay assistance applications related to intravitreal injections and retina-specific medications.  This role serves as a key point of contact for patients, guiding them through treatment, insurance processes, and financial assistance options.  Responsibilities include verifying eligibility, coordinating with payers, enrolling patients in financial assistance programs, and ensuring timely approvals to avoid treatment delays. This position supports multiple providers across locations and plays a critical role in maintaining efficient patient flow within a high-volume retina practice.

Core Behavioral Values 

• CLEAR ID: Collaborate, Learn, Empathy, Accountable, Respect, Integrity, Dedication
• These behaviors are based on Eyesight’s culture and values critical to support the organization’s mission of providing uncompromising care to patients. 

Requirements

Essential Functions

• Serve as a primary point of contact for retina patients, guiding them through treatment plans, insurance processes, and financial assistance options 
• Review retina clinic schedules to identify patients requiring prior authorizations 
• Verify insurance eligibility and benefit details for injectable medications and procedures 
• Obtain all necessary prior authorizations for retina injections, ensuring accurate ICD-10, CPT, and HCPCS coding 
• Submit supporting clinical documentation, including notes, diagnostics, and test results, to facilitate approvals 
• Track, follow up on, and document all pending and retro-authorization requests to prevent treatment delays 
• Maintain accurate logs of prior authorization statuses, expiration dates, and coverage limitations 
• Communicate with Medicare and commercial payers to resolve issues related to authorization delays or denials 
• Appeal denied authorizations as appropriate 
• Coordinate and apply for manufacturer-sponsored copay or patient assistance programs for eligible patients 
• Discuss treatment-related costs, payment options, and financial assistance programs with patients 
• Collaborate with providers to communicate coverage-based medication options for retina treatments 
• Collaborate with retina technicians and schedulers to ensure patients are cleared for treatment 
• Ensure all prior authorization and financial assistance outcomes are accurately documented in the EMR/PM system 
• Upload and maintain updated insurance and authorization documentation 
• Assist with insurance verification and accurate plan entry when discrepancies are identified 
• Respond to patient and clinic inquiries regarding billing, coverage, and assistance programs 
• Maintain current knowledge of payer-specific rules for specialty drugs and retina procedures

Qualifications

• 2+ years in a medical office setting
• Strong knowledge of insurance verification, prior authorizations and specialty drug coverage – ophthalmology or retina experience strongly preferred
• Understanding of CPT/ICD-10 and HCPCA coding
• Strong analytical, problem-solving, and organizational skills
• Excellent written and verbal communication skills

Preferred

• Proficiency in EMR/PM systems (experience with ModMed a plus)
• Knowledge of HIPAA and patient privacy standards

Work Conditions

• Professional healthcare setting, including clinics, administrative areas, and patient-facing environments
• Noise level ranges from quiet to moderate, depending on location and activity
• Potential exposure to infectious diseases, bodily fluids, or cleaning agents in accordance with standard protocols

Physical Requirements

• Ability to sit, stand, and walk for extended periods
• Frequent use of hands and fingers to operate medical or office equipment
• Clear verbal and written communication; ability to hear and understand speech in person and by phone
• Close vision required for reading small print and viewing computer screens
• Occasional lifting or moving of objects up to 25 pounds
• May involve reaching, bending, stooping, kneeling, or other physical movement
• Ability to manage multiple priorities and maintain professional interactions in a dynamic setting